Female genital mutilation at Cornell? It's complicated.

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By now, you've heard the story about Dix P. Poppas, a pediatric urologist at Cornell University who published research dealing with a new technique for cutting oversized clitorises off of baby girls—and who used repeated examinations with a vibrating device* to verify, as the girls grew, that their nether-region nerve endings still worked. Dan Savage brought the initial posting on the Hastings Center's Bioethics Forum to broader public attention. Jezebel focused in on the part about the vibrating device. And Slate tried, and mostly failed, to find a contrarian "this isn't as bad as it sounds" angle.

As I read up on the story, though, I realized that nobody was explaining what was really going on here. Not fully, anyway. See, Poppas wasn't just pulling this idea out of his rear. And his patients weren't just little girls with slightly larger-than-average clitorises. In fact, the children were born intersexed—genetically female, but with ambiguous genitalia caused by a hormone imbalance. For these girls—and other children born with a variety of intersex conditions—genital surgery in infancy is standard practice. It happens all over the United States every day. The only thing that makes Poppas different was his follow-up procedures (a whole problematic can of worms that the sources above cover very well.)

But just because Poppas was following standard practice doesn't mean there's nothing to question. Doctors recommend genital surgery for intersex babies on the assumption that it would be psychologically damaging to grow up with private parts that are so outside the norm—your parents wouldn't be able to handle it and would reject you, you'd be tormented by peers, etc. But the thing is, there's no evidence that this is true. We don't know that intersex people who've had the surgery lead happier lives than those who haven't. Nobody has ever systematically followed up with the patients to find out.

Here's what we need to be asking questions about: Why are we performing purely aesthetic surgeries that come loaded with a lifetime of possible side-effects—from incontinence to inability to orgasm—when patients are too young to consent and there's no evidence that the surgery offers them any benefits?

*NOT an actual dildo vibrator, as I understand it. Read the Slate piece for more detail.

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You might think the idea that "people are freaked out by ambiguous genitalia and happier with normal" would just be common sense. But reality and common sense don't always align. There's been no research on outcomes for intersex adults, but there have been lots of intersex adults who've spoken up about being miserable with the results of childhood surgeries. Realistically, there are probably people who are happy with their surgeries, too. But, with the evidence we have, all we can say for sure is that there's no guarantee surgery is the right way to go, psychologically, for each individual. Meanwhile, the standard practice is to not offer individual choice.

I'm going to go out on a limb and call that wrong. But this isn't just oppressive to people who don't fit a neat gender binary. It's also not scientific medicine.

I love modern medicine. The skeptic movement has turned me into an advocate of evidence-based medicine—the simple idea that tradition, anecdote and common sense aren't good enough reasons to ask a patient to spend money and risk side-effects on a treatment. If there's no solid, scientific evidence, what you're doing isn't medicine. It's woo-woo magic.

But I think people often forget that this doesn't just put the smack down on things like homeopathy and chiropractic. Mainstream medical treatments have to be held to the same standard. And they don't always measure up, either.

Case in point: My lower back. Since I was 21, I've been privileged to enjoy periodic bouts of horrible searing pain shooting around my hips and down my legs. Doctors tended to prescribe me muscle relaxers and tell me that, at some point, I'd probably have to have surgery. But about a year and a half ago, I got a new doctor, Jonathan Tallman. And he was different. Instead of relying on anecdote and common sense, Dr. Tallman looked at the research. He told me that studies didn't really show evidence of success for muscle relaxants, or surgery, or chiropractic, or any number of expensive treatment options. In fact, he said, studies were often stopped because the control groups—who were just doing moderate, daily exercise—were the only ones who saw any reduction in back pain. "So, why don't you try exercise," he said. I haven't had any back pain since.

That's evidence-based medicine in action.

Dr. Poppas? That's what happens when well-meaning doctors stop practicing medicine and start practicing woo-woo magic. Poppas wanted to introduce a surgical technique that would preserve as much nerve tissue as possible. That would normally be laudable. But what he should have been doing was studying whether the surgery was necessary at all.

Research and follow-up studies could end up showing that intersex children do get psychological benefits from growing up with "nomalized" genitals. I don't know. Nobody does. But you can't just assume a treatment is successful because you think it ought to be. Until there's evidence, one way or the other, surgery on the genitals of intersex children shouldn't be any more legitimate than trying to fight off malaria with a sugar pill.

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Poppas wanted to introduce a surgical technique that would preserve as much nerve tissue as possible. That would normally be laudable. But what he should have been doing was studying whether the surgery was necessary at all.

I have no idea what his personal motivations were for performing this study, but it seems to me that he’s saying, “If this has to be done, do it this way to make the damage as minimal as possible.” and leaving the actual decision of whether to perform genital surgery up to someone else.

Is that less ethical then coming out and saying, “We shouldn’t do this?” Maybe, but perhaps Poppas is a pragmatist who knows that there are going to be parents who order the surgery performed anyway, regardless of whether scientists like him come out strongly against it. If he can’t stop it, at least he can limit the damage.

Hey, Maggie? Thanks for being so awesome. I love all the bloggers here, but you’ve consistently raised the level of discourse with these thoughtful, well researched posts. I look forward to your posts, because they always give me something to think about.

And on topic? I’m glad you’re approaching this from this angle, because surgery on intersex infants -should- be a very controversial topic, but no one seems to care. Which is pretty tragic.

I read this: http://www.scientificamerican.com/article.cfm?id=going-beyond-x-and-y&print=true in SciAm a couple years ago. I think (and hope) some medical professionals are looking at evidence. But, “…Lee, a pediatric endocrinologist at the Penn State College of Medicine, cautions that much more work lies ahead to fill in data gaps. For instance, physicians have not measured how their choices affect patients over a lifetime.”

Excellent point, and I must say that your conclusions seem thought out.

I would say that I would not have wanted to go through gym class at school with this sort of condition. Choice is important, and so is adult responsibility (making hard choices for a child’s wellbeing for growing up in the society into which the child was born).

I would tend to agree with you and err on the side of choice of the individual. But the reasoning from the other side seems founded on wishing to do the right thing as well.

“If this has to be done, do it this way to make the damage as minimal as possible.”

But the testing doesn’t accomplish that. Once bits are cut off and nerves are severed, it doesn’t matter if his medical vibrator shows the girl has full sensation or nothing at all.

They can’t bits back on later. These exams just add another layer of what would be called child sexual molestation in any other context (and sexual molestation carried out while a parent watches and explicitly approves), on top of the already horrifying mutilation.

Calling this sexual molestation seems a bit extreme, although I admit to not having read the details of what this guy is up to so perhaps I am missing some key info.
From what I gather, his intent is medical rather than sexual. Whether it is the right thing to do or not is a legitimate question which should be answered with science.

That’s beside the point. As an adult, you consented to being examined. The claim put forward in some of these comments is that the child, in addition to lacking the capacity to freely consent to being examined, won’t understand the distinction between medical examination and sexual contact.

I don’t know if I agree with that claim, but I do agree that the child’s situation and your own example are not comparable.

Why would a prepubescent child see a medical exam as sexual in the first place? Children are taught from an early age that touching by doctors and nurses is okay, even on their private parts.

Dr. Poppas’ patients were examined with a parent and a female nurse practitioner in the room. A touch that is sexual in one context is neutral in another. Child sexual abuse is marked by shame and secrecy and it is sexualized in context–i.e., the abuser regards the touching as sexual and the child picks up on that.

Pediatric urologists touch children’s genitals for a living and they’re probably very good at putting kids and their parents at ease in these situations. Dr. Poppas got rave online reviews from parents of patients who raved about his bedside manner. (None from CAH girls that I saw, but lots from parents who took their kids to him for other reasons.)

Girls with CAH have a chronic medical condition that requires them to be poked and prodded all over from birth onwards, whether they get the surgery or not. By the time they’re old enough to have surgery and post-surgical testing, they’re used to being examined. A lot of people who have chronic illnesses get even more blase about intimate exams than your average person.

Sure, the doc is just a cog in this system. But kudos for posting this article Maggie.

For me, it’s all the decision of mutilating another individuals body, without their consent, that really gets me mad. These kids were born that way – great, we can label it as being a specific gene, but that still just means it’s uncommon, not ‘wrong’ and something to be fixed.

I’m male, and circ’d, but chose to leave both my boys intact, because it’s thier choice, not mine. Babies also do not need to be introduced to this world by being strapped to a cross and cut in the most sensitive area. Then, the poor kids have an open wound in thier diaper — really bad idea!

And the whole campaign to rid Africa of AIDS by encouraging male circumcision is ludicrious – flimsy evidence, but … hmmm… who are the people that are on the ground in Africa that are bringing this myth from the western world? yup, missionaries. Mores and taboos don’t change that fast…

Reality is that a parent must make all decisions for a child. Whether to circumcise, whether to vaccinate, what to feed them, etc. You cannot say “it’s a matter of choice” when it’s a baby who cannot yet make a choice.

Are you also against vaccination? Since it should be a choice by the child?

No, parents cannot and should not make all decisions for their children. I say ‘cannot’ because parents don’t have complete control over their children, they simply hold a majority of the rights of their child until their child reaches the age of majority.

In this case, even if there is conclusive evidence that there is a need for this surgery, there isn’t any medical reason not to wait until the child completes puberty.

First, there isn’t any way to tell what their genitalia is going to look like until then. Second, it wouldn’t be a problem until then, anyway. Third, by the time they reach that age, you can explain what’s going on, and they’ll be able to understand what’s happening to them.

Or they can petition for a court-appointed guardian to keep the crazies away from their genitals. You know. Whichever. :)

Even if having ‘abnormal’ genitalia is problematic, I can’t see how it would be more problematic than having everyone in your life tell you how bad your genitalia was, and how you had to be fixed, at age six. Can you imagine what they must be feelings? A complete loss of control over their bodies, just when they’re starting to desire autonomy and exhibiting embarrassment, culminating in years of sexual abuse. (You can abuse someone with good intentions, by the way.)

Remember that Poppas is completing these surgeries on six-year-old girls. They are more than old enough to understand that they have differences that have to be ‘fixed’, and more than old enough to feel a variety of negative feelings about themselves, their parents, the procedures, the follow-up procedures…

Further, he’s been checking them every year since then. Can you imagine hitting puberty and having someone stimulate you and record your sexual response – in front of your parents, no less?

If the idea is to avoid causing psychological problems, they’ve certainly missed the mark.

Assuming everyone in the kid’s life is telling her her genitals are “bad”, would it be worse to “fix” them, or leave them as is? That’s a genuinely difficult question. The answer depends on the the details of the child’s medical, developmental, cultural, and family situation.

Consider an example. Imagine you live in a small, deeply conservative town. Your little girl is born with a de facto penis. Can you safely leave her in daycare where a stranger will change her diapers? If you live in a liberal mecca where boys are allowed to wear dresses to school as a matter of course and everyone is raised on Free to Be You and Me, it’s one thing. What if you know that your daughter, and possibly her family, will be ostracized by the community for having a penis?

It’s one thing to insist say that parents should accept their children as they are and seek therapy if necessary. It’s quite another to ask everyone to live with the consequences of that high and admirable standard.

Assuming everyone in the kid’s life is telling her her genitals are “bad”, would it be worse to “fix” them, or leave them as is?

And if you live in some all-white enclave and you adopt a non-white baby, are you going to bleach it to avoid questions? Should you send your gay teenager to be psychologically mutilated if you live in some homophobic backwater? You protect your child by talking to neighbors, teachers, friends — not by slicing it up, physically or mentally.

It’s quite another to ask everyone to live with the consequences of that high and admirable standard.

Parents have to defend their children from ill-informed teachers, administrators, doctors all the time. It’s part of the basic job description. Anyone who doesn’t want to take that on should use reliable contraception.

The vast majority of the potential dating pool would say no. That’s a pretty good reason to have the surgery right there. It’s not just mindless prejudice at work, it’s also orientation. Genital-shape is a legitimate criterion for a sexual relationship. You can’t order gay people to be attracted to opposite-sex genitals or straight people to like same-sex genitals.

Either the girl with severe CAH is going to grow up to be attracted to guys, in which case a mini-penis will probably be an issue for most potential mates. And/or, she’s going to be attracted to girls. Most lesbians probably aren’t much better-disposed towards mini-penises than hetero dudes. Even if she identifies as male, it’s not like leaving her genitals alone will result in a normal, functional penis.

You might say that future dating is irrelevant to a child and therefore the decision should be deferred. But the outcomes from the procedure aren’t as good if you wait until the kid is of legal age to decide.

Imagine being a teenage girl with ambiguous genitalia who is told that she has to go through surgery that’s now going to be much more painful and debilitating than it would have been if she’d had it done earlier. I would be really pissed off if my parents had punted the decision and left it up to me to face when the options were objectively worse.

I agree! It’s totally better to just assign a sex, surgically mutilate, and hope that works out. It won’t cause trauma or problems.

I mean, the case of David Reimer worked out perfectly and we should all rally around Dr. John Money for his wonderful handling of that situation (resulted in 2 suicides)http://en.wikipedia.org/wiki/David_Reimer

But why make such a decision before the child has reached puberty to know the full effects of the surgery, or before anyone else will even see the child’s genitals? That is when the individual can then have a choice. Plus, the designation of “ambiguous genitalia” is literally a few millimeters from what is considered “normal.” Most surgeries on intersexed children are not chosen for health reasons (unlike vaccines, for instance), but are done out of fears that have yet to be proven rational.

I have to wonder if you read the thread before asking this. This may be the essential interesting question to be worked oiut here: there are some good reasons, for some cases, where there’s an advantage to not waiting.

The hard cases here are where we’re confronted with an infant with ambiguous genitalia and no other cues to their future gender identity. But that does not describe every case where genital surgery might be called for. If an infant has ambiguous genitalia where the cause is not associated with nonstandard gender identity, then there ARE reasons to favor surgery before puberty rather than after.

Genital surgery in infancy, all else being equal, is likely to produce better wound healing and better nervous compensation compared to the same surgery performed on an adult. The hard part is making the call about which cases merit taking the risk in infancy.

This is indeed a very complicated issue, and if folks want to read a very nuanced, compassionate look at the issue of intersex children from the perspectives of doctors, parents, and intersex people themselves, you should take a look at Katrina Karkazis’s Fixing Sex. Karkazis teachers at Stanford. Here’s a link to the book: http://www.dukeupress.edu/Catalog/ViewProduct.php?productid=13370

Sadly what it ultimately comes down to is doctors and parents saying, “You’re different and we’re not comfortable with that, so we’re going to change you so that we are.” They may justify it by claiming the child will be “better off” (granted, in terms of “fitting in” that would be the case), but the only “evidence” they have that this is true overall is their own prejudices.

The problem is that Dreger and Feder, the idiots who wrote the original post, are two key proponents of reframing “oversized” clitorises as “disorders of sex development.”

By characterizing these infants as having a disorder rather than a naturally-occurring trait, they have doomed many of these infants to “normalizing” surgeries. It’s the law of unintended consequences at work, because their short-sighted push for new nomenclature that conflates function and cosmesis is fueling a resurgence in this kind of neonate surgery. Physicians see the word “disorder” and assume they need to restore “order” through drugs and surgery.

Dreger and Feder say this surgery is bad (it is), but they are the main reason it’s seeing a resurgence. Dreger’s views are reviled by the world’s largest intersex support group for good reason.

Here’s a link to the FAQ page of ISNA, the Intersex Society of North America, where you can find more information : http://www.isna.org/faq/.

I remember hearing representatives from this organization speak at a GenderPAC conference years ago and their stories were amazing. One of the most startling realization from hearing these people talk about Intersex issues, is that most of these surgeries are cosmetic. They are about fitting in to a gender binary on a superficial level. One man that spoke said he was raised as a girl – his genitals had been surgically altered in infancy – but when he reached puberty, his voice changed and he began to grow facial hair. Apparently this is a quite common occurrence in these cases. There are so many factors that go into determining “male” or “female,” and often doctors that take these drastic surgical courses of action make the wrong decision, and end up creating much greater harm in the long run.

Another startling thing to realize is that according to ISNA’s page, 1 in 2000 babies are born intersex.

My wife and I used similar reasoning when we decided not to circumcise our son, a decision that was a bit harder to make than it really should have been. The urge to conform can be a powerful force indeed.

As someone who is inordinately fond of their genital bits, I’m horrified that people would remove them from those who can’t consent.

I happen to have the male variety of genital, which, for those who don’t know, is an endlessly entertaining bit of flesh. If I had the female variety, I assume would be just as enthralled with it. In fact, I believe I would be just as enamored with my fun bits if they took the form of Quato from total recall.

Who’s to say that these kids won’t live a normal, healthy, perverted life like the rest of us?

On the supposed social necessity of genital mutilation of intersex infants –

You *don’t need surgery to assign a gender to a baby.* They won’t be using those bits for anything other than their excretory function for many years. Hopefully nobody is seeing them except doctors and those who change their diapers.

Pick a name, pick a pronoun, and go with it. There’s a significant chance you’ll guess wrong, but fortunately names and pronouns are a lot easier to change than surgical removal of your genitals is.

When that baby has become an adult, surgery will still be an option. They can assess their particular risks (incontinence, loss of sexual function, etc) and benefits themselves. And if they want it, results will be better on an adult because their body isn’t going to get any bigger, and the patient can talk.

Maggie is absolutely right. The scientific method should be employed in determining what effect this type of surgery has on the recipients throughout their lives. (And that is in part what Dr. Poppas seems to have been doing.) Without that data, it’s all just uninformed bias and speculation on both sides.

As for the ethical issue of choice in the matter, I’m actually undecided. Just to play devil’s advocate (since most comments seem to be firmly on the side of necessary consent), how would this surgery compare with, for example, surgical repair of cleft lip in infants? That’s not a necessary surgery, either, and its effects are mainly (though not entirely) cosmetic, yet there’s no outrage about it that I’m aware of. Why would parental consent not be sufficient, especially given that the child will not be able to legally consent for 18 years? Could our outrage be misplaced in the case of genital surgery due to mental association with the LGBT rights movement?

Also, I really don’t think this could be classified as sexual molestation, unless practically every visit to a gynecologist or urologist is also.

“You cannot say “it’s a matter of choice” when it’s a baby who cannot yet make a choice. ”

It’s a matter of choice, because there is no reason it has to be performed on an infant incapable of choice. Vaccinations have to happen in early childhood to be effective. Irreversible reconstructive surgery with dubious benefits can wait.

Whenever you do a nerve-sparing procedure, it’s only responsible to follow up with the patients to find out whether the procedure actually worked. Nerves may heal slowly. Just because the patient doesn’t have sensation 6 weeks after surgery, or 6 months after surgery doesn’t mean that sensation won’t return after a longer period of time.

If the patient starts out having sensation and loses it, that could be a sign of treatable complications.

If there is nerve damage, it’s important for doctors and other health care providers to know exactly where it is. Let’s say the patient grows up and is having trouble reaching orgasm. That’s pretty common in the general population of intact women. So, is this woman unable to climax because of lack of sensation due to the surgery, or because she has an underlying hormonal imbalance/chronic illness (i.e., the CAH that made her genitals ambiguous in the first place), or just because she isn’t getting the right kind of stimulation in bed? If the doctor can look at her chart and say, “You have slightly decreased sensation in area A, but normal sensation in areas B and C. Have you tried position X or toy Y?”

A lot of the time, people ignore the advantages of early surgery and talk as if feminizing genitoplasty in adulthood is as likely to be successful as surgery undertaken in childhood. There’s a real biological cost to waiting until adulthood to do the procedure. The structures are closer together in infants and they tend to heal better. Besides which in infancy and early childhood, body image and sexual response are still developing. Men who were circumcised as infants adjust a lot better than those who are cut later in life. (There are some confounding variables here, but studies have shown that the complication rate is much higher for later circs.) I’m not saying that male circ and feminizing genitoplasty are otherwise analogous, but it’s a familiar example of how genital surgery can be easier to tolerate in infancy. Sometimes at a bris the baby doesn’t even cry when the mohel cuts his foreskin off. It would be torturous to do the same thing to an adult.

The vast majority of girls born with ambiguous genitalia grow up to identify as heterosexual women (which you’d expect given that they are genetically female with normal uteruses and ovaries). Which is a better life: Your parents take care of this for you when you’re too young to remember and you grow up without having to worry about it; or, you grow up feeling weird until you have painful surgery as an adult that you will definitely remember and probably won’t turn out as well; or, you grow up with genitals that exclude you from dating the vast majority of people that you would be sexually interested in? Heterosexual guys, be honest, how many of you would date a girl with a mini penis and scrotum? No judgments. People like what they like. Chances are, if you’re a straight guy, you want to date a girl with a vulva and a vagina.

In cases where the clitoris is just larger than average, obviously we should leave well enough alone. Three cheers for big clits. However, I think there’s a case to be made for correcting severely masculinized genitalia in infancy on early childhood.

Being intersex isn’t just a cosmetic issue. It’s an issue of identity and social status. We all know how traumatic it is for some trans people to grow up in bodies that don’t match their sense of themselves. It’s not hard to imagine that it would be traumatic for someone who is genetically, socially, and otherwise anatomically female to grow up with genitals that look more like a penis and scrotum than a clitoris and labia. Those of you who are males in male bodies and females in female bodies, aren’t you grateful for that?

Before people form an opinion on this subject, it’s important to have some idea of what we’re talking about. Check out this interactive graphic from the Hospital for Sick Kids in Toronto (an center of excellence in pediatric endocrinology, respected by both Drager and her critics): http://bit.ly/a8oh2w The graphic shows the spectrum of what the genitals of girls with CAH look like. All the subjects in Poppas’ study were at least a Prader 2, the majority were much further along the masculinization scale.

When surgery comes into play, we’re not just talking about clitorises that are “too big” for a career in mainstream porn. It’s misleading to describe this surgery as purely cosmetic. It’s like correcting a cleft lip or a cleft palate. CAH can cause birth defects. There’s a lot of normal variation in the size of the clitoris, and that’s all well and good, but we’re talking about a symptom of a disease.

Some intersex activists want to have it both ways. In some contexts they argue that intersex is its own legitimate identity that has as much right to exist as the tradition gender categories. Then in the next breath they will argue that feminizing genitoplasty is merely cosmetic surgery, i.e., something done to make a girl’s genitals “prettier.” If feminizing genitoplasty is merely a cosmetic tweak, that undercuts their argument that surgery robs intersex people of their identity.

We don’t know that intersex people who’ve had the surgery lead happier lives than those who haven’t Nobody has ever systematically followed up with the patients to find out.

This is false. While I wouldn’t say there is a lot of research out there, studies have been done. I just did a PubMed search and am providing select results below. I have no expertise in the area and read none of the cited abstracts. Your hypothesis still might be correct, but your statement about a lack of research isn’t. I found the below studies by searching for “Quality of Life” and “Intersex.”

My personal opinion: While it’s tempting and easy to think the medical establishment would overlook something like long-term outcomes of intersex surgery just to conform to some conservative concept of gender, that didn’t occur. The overwhelming majority of neonatologists and pediatricians care very much for the long-term wellbeing of their patients and families. Some of them are pursuing additional research to confirm the medical care they provide is achieving the optimal outcome. Even if further research is warranted, they deserve credit for their efforts so far.

I don’t mean to sound confrontational, but I’m not sure why you would insist that we refrain from speaking about male genital mutilation too. The same argument these ‘doctors’ are using (“well, it doesn’t completely eliminate the ability for the person to feel sexual pleasure and it makes them ‘normal'”) to harm girls is the same tired argument that is used when harming boys.

The fact of the matter is that for nearly 30 years, all medical organizations that have taken a position on routine circumcision have said that they do NOT recommend it. The fact that it occurs at alarming numbers in certain countries, including the United States, is an important reason to discuss it when it is topical. I understand that you do not want this discussion thread to be derailed, but I don’t think it is not on-topic to discuss the EXACT SAME THING as it happens to men. If nothing else, it may provide an additional perspective into why this is going on.

As far as those that try to conflate circumcision with vaccines, there are three incredibly important differences.

1. A vaccine does not permanently remove any part of a person’s body. It does not involve surgery, it does not carry the risk of lifelong physical and emotional trauma, and it does not leave a scar.

2. Vaccines completely protect us from overwhelmingly bad, life-altering, highly contagious and highly fatal illnesses that, un-vaccinated, you would have no ability to avoid since they are largely airborne/waterborne. Circumcision, in contrast, provides *at best* a small reduction of minor afflictions like urinary tract infections and sexually transmitted infections that could be easily prevented through safe sex.

3. A vaccine provides herd immunity. You are not merely protecting the person that receives the vaccine from disease, but are protecting everyone else around them as well.

Genital mutilation of infants and children is the wrong thing to do whether it is a boy or a girl, normal or intersexed. It is something that has been exhaustively researched, and something that no medical organization recommends. It is not something that should happen, to boys *or* girls, and it is as important to dispel myths surrounding it as much as it is important to dispel myths about female genital mutilations.

I’m not sure why you would insist that we refrain from speaking about male genital mutilation too.

Because every thread about female genital mutilation turns into a angry sausage-fest. I’m opposed to all unnecessary surgeries on children, but I’m also opposed to threads on female genital surgeries turning into, “My dick! What about my dick? Why aren’t we talking about my dick?”

I am so glad you stepped in with the cock-talk-block. Given how well the conversation started (with Maggie’s post) it was disappointing (if predictable) to see the circumcision stuff start up so quickly. Not that there’s anything wrong with that debate, but there is certainly no shortage of places on the internet to pursue it.

A) Excellent piece, I’ve been reading every link and learning a ton of stuff that I can bring up at the next family Thanksgiving to make everyone super uncomfortable.

B) The clitoris is the only sexual organ which is exclusively for pleasure. Any doctor who suggested this surgery for my child would be nursing a head wound. The kid can figure out what they want to do with it, when they figure out what it does.

C) I’ve never found Boing Boing to be a sausage fest, so I say let fly with the anti-circumcision rhetoric. The steampunk, on the other hand…

Brilliant, open, thought-provoking post. Skeptical in the best and fullest sense of the word. I’d seen this case covered elsewhere but the extra context and the argument about intersex individuals just sat me down and gave me some homework.

For balanced criticism of alternative and mainstream medicine Ben Goldacre’s “Bad Science” blog is really good. What respect I have for alternative medicine I got from there.

“It’s not hard to imagine that it would be traumatic for someone who is genetically, socially, and otherwise anatomically female to grow up with genitals that look more like a penis and scrotum than a clitoris and labia.”

It would be hard.

But the risk of that also has to be weighed against the risk that you will surgically feminize the genitals of this infant, and then at adolescence realize this infant grew up to be a boy who wants their penis and scrotum back.

There’s no way to tell what gender these infants will grow up to be. The effects of hormones that can give an XX infant highly masculinized genitals aren’t just affecting the nether regions. These infants may have been neurologically masculinized as well.

And some infants who have feminizing genital surgery aren’t XX either – feminizing surgery is the default, and an XY infant may be subjected to it too (as well as surgical creation of a vagina, which has to be made adult-sized from the start because it will not grow with the body) if they’re deemed “too small.” It’s a decision literally made with a tape measure.

Actually, we do know from research that the overwhelming majority of girls with CAH grow up to identify as heterosexual women.

When a baby is born with ambiguous genitalia they get a genotype and a thorough medical workup to determine what chromosomal sex they are and what other sex organs they have. It’s much more difficult decision to assign a gender in some other conditions that cause ambiguous genitalia. CAH is a much easier case because these girls are unambiguously female except for a birth defect of the genitals caused by abnormally high androgen levels in utero.

If it’s an XX girl with CAH, she has a normal uterus and ovaries that are pumping out female hormones. The brain may have been masculinized to some extent. Girls with CAH are more likely to be tomboys as girls and more likely to be lesbians as adults. But brain development continues after birth. In the developed world, girls with CAH are immediately treated to bring down their androgen levels and restore more female-typical hormone levels. This hormonal therapy is to prevent life-threatening complications, not to enforce an arbitrary gender binary.

If you were born with a cleft palate that didn’t affect your ability to swallow or talk, but made you look abnormal, wouldn’t you want your parents to fix it right away, or wait to let you decide whether you wanted the surgery?

Think about what you’d want for yourself if you’d been born with ambiguous genitalia. Personally, if I’d been born with severe masculinized genitals due to CAH, I would rather that my parents opted for nerve-sparing surgery early on to give me the maximum chance at a normal life, physically and socially. Many women who had the surgery as children are capable of orgasm, even with the older non-nerve sparing techniques. The clitoris extends deep inside the body, the externally visible part is only the tip of the iceberg.

Other people may feel differently about what constitutes the best start in life, which is why this difficult decision should be left up to the parents.

CAH is not analogous to race. All races are equally healthy variants within the human species. The genitals of CAH girls are malformed due to a well-understood inborn error of metabolism. They don’t look like, or work like, normal vulvas or penises.

First off, add my compliments to the chorus thanking Maggie for taking an intelligent and nuanced approach to a very hairy subject. Would that we could all proceed this way when emotional or explosive problems must be discussed.

The link posted in #20 is really worth reading if you care enough about this to hang around and argue about it in this thread; in fact, I’m going to repost it in case doing so makes anyone that much likelier to read it (however, it is not my contribution. Thanks to Anonymous at #20.):

The link in #36 is informative on the subject and hand, and also interesting in its own rights and a nice bit of educational animation.

I don’t know enough about who Dr. Poppas’ patients are to have an opinion on what’s going on here, but I wanted to make a point that is often missed in circumcision arguments — which I’m not here to talk about! — and is even more relevant here. On the subject of consenting on behalf of infants to genital surgery vs. waiting until the child can consent on its own, not only are there differences in healing as pointed out by Anon in #31, but importantly, there are differences in the way the brain will react to destruction of peripheral nerves. The infant brain is not nearly finished developing when a child is born, and relies on sensory stimulation to guide that ongoing process. Just as newborns can scarcely see at first, their sensations of touch are highly disordered as the brain is still organizing itself in response to the incoming sensations. As a result, in the context of peripheral nerve damage, the early developing brain is going to make the best of whatever incoming information is left as it makes sense of those sensations and incorporates them into behavior. In other words, if I *had* to have some degree of genital nerve damage, I’d much rather have it as an infant and let my brain organize my yet-to-develop sexual behaviors around it then, then to have the damage later in life when the brain tissue on the receiving end of those nerves is already used to one standard of input and has less plasticity to respond to the new situation. And that brings up, again, what the real question is here: for these patients, how close does this come to a “have-to” situation? I don’t think anyone here knows, without a clear understanding of what’s motivating the parents and what the likely outcome of postponing surgery would be.

I love modern medicine. The skeptic movement has turned me into an advocate of evidence-based medicineâ€”the simple idea that tradition, anecdote and common sense aren’t good enough reasons to ask a patient to spend money and risk side-effects on a treatment. If there’s no solid, scientific evidence, what you’re doing isn’t medicine. It’s woo-woo magic.
Yes. Exactly So. I have rarely heard this put in a more concise and straightforward manner, and I love that you also specify that this principle applies to more than just you typical crackpot stuff.

The mutilation of intersexed newborn’s genitals is a horrible practice, and if I have any intersexed children, doctors who want to put them under the knife are going to have to go through me first.

I think we can see a similar woo-woo magic philosophy at work in the over-medication of our children, many of whom have close to a dozen prescriptions these days. Frequently the evidence for these drugs is incomplete, and they have never been tested in conjunction with each other, and our kids are paying the price.

We need to stop looking at modern medicine as some perfect solution. Like any complex answer to a complex problem, it is in fact. completely imperfect, fraught with unforeseen consequences, and never cut and dry.

Wrong. They grow up to be women. They have normally functioning ovaries and uteri, and usually produce normal levels of female sex hormones. Their external genitals are masculinized (among other physical effects). See the Prager Scale. Some of these children have no vaginal opening at all. If the cortisol issues in C.A.H. are resolved treated (I assume no one is going to have a problem with that), these children can have normal pubertal development, but it’s hard to menstruate without a vaginal opening. Some surgery seems unavoidable. Should parents be able to consent to surgery to give their daughters a vaginal opening? Or should we wait until these girls are 18? I know what I would decide in that case. Mileage may vary, it seems.

Q. Can children grow up mentally healthy if they have ambiguous genitalia?

A. I think that these sexual assignments often create more problems than they solve. The children grow up with unhealthy secrets. What the kids tell me is that while they didn’t know they were males, they always knew something was wrong because they were “too different” from all the other girls.

In my psychiatric practice, I’ve had families where the parents asked me to be with them when they told their children, “You were actually born a boy.” That turned out to be a critical moment because every child converted to being a boy within hours, except for two. With those two, they refused to ever discuss their sexual identity again. Still, none of them stayed female.

Q. Because of all this new research, is the accepted standard of care of intersex children changing?

A. There’s no one standard now. Five years ago, a genetic male child born without a penis or a severely inadequate one almost universally would have been assigned female at birth. Today, about two-thirds of the pediatric urologists say they wouldn’t go that route, which means that one-third still might. That says that we’re not sure of the right way, yet.

It’s an irony to me that surgeons have gotten the worst criticism from intersex adults for these practices. Certainly psychologists and endocrinologists were also involved.

From what I’ve seen, it’s the surgeons that have made the biggest changes the fastest. I think part of the reason for that is that surgeons do things to their patients physically and are, therefore, very sensitive to doing the right thing.

Q. What conclusions do you draw from your study?

A. That sexual identity is individual, unique and intuitive and that the only person who really knows what it is is the person themselves. If we as physicians or scientists want to know about a person’s sexual identity, we have to ask them.

FTA…. “In fact, the children were born intersexedâ€”genetically female, but with ambiguous genitalia caused by a hormone imbalance. For these girlsâ€”and other children born with a variety of intersex conditionsâ€”genital surgery in infancy is standard practice. It happens all over the United States every day. The only thing that makes Poppas different was his follow-up procedures (a whole problematic can of worms that the sources above cover very well.)”

But you are right in a way, we’re talking about infants who have abnormal genitalia. Whatever caused it is sort of irrelevant to the conversation – except for the fact that weirdness in hormones that causes these physical abnormalities can also cause differences in neurological development.

If there is a difference between the gender identity and the genitalia, this frequently causes fairly significant issues.

While the argument for “if we don’t, they face possible trauma” is possibly valid, nobody really mentions that the alternative isn’t perfect, in fact, it can lead to significant problems (incredibly high rates of depression, self harm, suicide, etc)

OK, after a little research from on the website for the Intersex Society of America, I guess these people are intersexed, since intersexed refers to any person with a reproductive anatomy that doesn’t fit into “typical definitions of female or male.” (but just because Maggie writes it in the article doesn’t make it truth — “FTA” is kind of irrelevant when one is disputing facts.) But, I stand corrected.

However, this is not gender assignment, and that is the real point. These are women. XX women. My point was that all the discussion about how bad surgery is on people when you change their gender assignment or decide their gender in an ambiguous situation is irrelevant. These are women. The surgery isn’t changing that. So let’s argue about reconstructive surgery or something related.

FWIW there is significant pressure from certain groups (especially Catholics, evangelicals, etc) to limit the definition of intersex as much as possible in an attempt to erase them from the medical community. So your confusion is understandable because these wonderful people go around pretending that intersex stuff never happens because God only created man and woman in the bible.

Personally, I’d argue that a surgery to create something that is masculine looking into something feminine looking is gender assignment.
And we are talking about cases of ambiguous genitalia. While we may currently use karotype testing to determine whether the child is XX, XY or whatever, this practice is effectively the same as was practiced in the 50s and 60s. I’m sure there are cases where a karyotype isn’t even done.

I don’t believe there is sufficient ethical restraint by doctors. In fact, I think a significant part of the medical community is engaged in incredibly questionable ethical practices. As a result, I find it incredibly difficult to believe some people when they say it is “necessary”

Under current medical guidance, we routinely abort chromosomally odd fetuses. IIRC, one study I read recently showed that XXY fetuses were aborted 60% of the time.

There are currently doctors recommending prenatal use of hormone altering drugs to prevent these sort of birth defects, but they also take it further and suggest that the use of these drugs can also prevent homosexuality in women. Take a look at this.

It gets worse. There’s just a lot of really ugly stuff out there and to be blunt, our handling of intersex infants is a disgrace on the medical community. Skepticism of both motives and techniques is a good thing.

It doesn’t matter if I was born with a dick, a clitoris, a vagina, and/or a tail; I do not want my parents or a physician cutting anything off!

In my community (urban, young adult, anarchist) gender is a personal choice. Some of my friends have transitioned or chosen neutral or mixed gender identities. I think it’s awesome to see the full diversity of human potential. It angers me that people in positions of power would risk robing people of sensation and parts of their bodies in a misguided attempt to conform to cis-gendered heteronormative Western/Christian identities.

Even if 99.99999% of these girls remain female identified; if any of them loose sensation or psychological completeness, than unnecessary harm was done. I’m upset that myself or one of my friends or partners may not be complete because of the dominant culture’s drive to make everyone homogeneous. We are human fucking beings, not plastic dolls!

I wonder if people are generally in agreement that it makes a difference whether you’re talking about patients about whom there is unresolvable ambiguity about their likely eventual gender identity (ambiguous genitalia without knowledge of the cause), vs. patients whose physical gender ambiguity is the result of a known syndrome that is not associated with gender identity issues in adulthood?

In other words, imagine that Dr. Poppas’ patients are all CAH patients (which is verifiable with physiological tests). And suppose that XX CAH patients are no more likely to have transgendered identity as adults than XX babies with no genital anomalies. (*I have no idea if this is true, to be clear*). In this were true, then an XX CAH patient with an enlarged clitoris, who grew into a male-identifying adult, would be both rare, and lucky – s/he would have sort of accidentally “scored” genitalia that was more concordant with his/her subjective sense of gender. But – would such a relatively rare case of good luck obligate a medical policy toward the remaining XX CAH population of waiting until adolescence for any surgery?

I don’t actually have a strong opinion here, I’m kind of thinking out loud.

Surgery has a known and universal consequence: scar tissue. When it comes to sensitive nerves dedicated to pleasure that few others will ever see, scar tissue is a worse offence than when it is either life-saving or in a more sensation-neutral area. Genitalia, tongue, nose, fingertip — sensation central.

You are right that surgery on children has a better outcome –for the rare CAH XX individual with normal uterus and ovaries but a completely blinded vagina, surgical opening might be indicated in consideration of puberty, especially since surgical reconstruction of the previously-empty scrotum would be relatively trivial. Of course, taking 1-4 years to decide this is no big deal.

Any kid being teased in the locker room at this level of detail is being sexually harassed — it shouldn’t be known from changing clothes. Also, how about those thalidomide babies? We couldn’t fix them, their disability was obvious, and yet they managed (as much as most of us) to participate in society. Physical perfection is an illusion at best.

The main point of the modern interpretation of the Hippocratic Oath is to maximise benefit while minimising hurt: First, do no harm. So don’t cut or dose unless you have to. If you don’t have to, you better have one *hell* of a compelling argument.

All this takes me back to my two year stint as a pre-nursing major, Greensboro, N.C., 1994-1995. Lab classes taught by real nurses to a crowd of (mostly) working class women who were back in school hoping to get a better job as a nurse.

When we did the section on neonatal nursing, I’ll never forget, the nurse who was giving a talk on what it’s like in the real hospitals told us that TONS of babies are born with ambiguous genitalia. And that they are almost all made female, and that in order not to alarm the parents, usually the families are told that there is a ‘minor congenital irregularity that can be quickly set right’ or sometimes the existence of a teeny penis is referred to as a ‘flap of skin’. She told us that these babies were hermaphrodites, but that the parents never knew and it was standard practice.

She also told us the numbers were a lot closer to 1 in 10 than 1 in 1000.

Later I heard in other classes at other universities how there is still no scientifically agreed-upon definition of sex. Because, see, if you base it on genetics, is a man with a functioning penis but anything other than XY chromosomes no longer a man? If it depends on sex cells, does a person who never produces sperm or egg lack a sex all together? And if you base it on phenotype, the penis or the vagina, what happens if yours is mutilated? See?

So, for all the comments from people sure this is about girls, or about intersex people, or about multi-sex people, or about men and circumcision (chuckle), it’s about babies. That’s enough for me.

I’m actually really happy to read these comments, maybe the future is going to be nicer than the past in this regard. One thing for sure, parents, DON’T let your doctors or hospitals cut anything without a full investigation. Flap of skin, my ass.

My head hurts. In one way, Poppas is the kind of doctor the world needs. He is someone who is striving to push the envelope of medical practice for the ultimate goal of making a better life for the patient.On the other hand, if he is getting seedy kicks out of this it is just plain wrong.

In the end of the day I admire that this guy is trying to add knowledge to his field, rather than just stagnate and make the $$$, but I just wish he would leave the follow-up “check-up” to someone else. That way there would be very little space in which the ‘think of the children’ crowd could bitch about his ethics.

PPS: I notice that many people in the comments seem to be coming down on the side of the “leave the child as-is” argument.

While you and I may understand that there is no such thing as ‘normal’, just variations on a theme, it is a very different matter in the real world where;

A) people are fucks sometimes
B) children learn by recognising patterns and grouping things mentally into categories

You might be able to teach your disfigured child that their disfigurement is nothing to be ashamed of, but good luck protecting them from the grubby-handed demons they will encounter in school. And what happens when they discover that what they have down-there is not like anything other people have? While I hate the prescribed idea that blue is for boys and pink is for girls, there is no denying that this and similar ideas are pervasive in public opinion and, to a certain extent, drive development of each person’s identity.

Many people are saying “you can’t go back and add bits after the change has been made. the change is for life”. Fair point… but isn’t it equally worth pointing out that emotional scars are often as permanent as physical ones? You can’t go back and reboot your childhood.

A final thought: If your child was born with a cleft lip or pallette, wouldn’t you want it fixed? So why is genetalia any different?

A cleft lip or palette looks like it would interfere with speech or eating. Not to mention that we have an innate tendency to see facial asymmetry as unattractive. A strong argument can be made for repairing such facial damage.

Having more intact genitalia can only make sexual function better. I don’t see how a large clitoris or even a full penis on a female is bad thing. In a sane society, genital variation (at least variation that doesn’t cause painful menstruation, urination, or reproduction in hetero cases) would be celebrated for it’s uniqueness and be considered MORE desirable than a “normal” penis or clitoris. (I think this is already the case within some queer and radical communities).

Also I believe (although I have no personal experience with this) that m2f trans-gender prostitutes command a higher price than cis-male or cis-female prostitutes. The supply of females with penises is far lower than the demand of males who want to have sex with such a woman. You don’t need to be a radical left wing queer liberationists to oppose cutting off female genitalia that resemble a penis…one can make the right wing free market capitalist argument based on simple supply and demand (tongue firmly planted in cheek but I bring up this case to show that our social norms don’t match up with the sort of gender identities that people accept behind closed doers).

Its ironic that you used a personal anecdote to support evidence based medicine.

EBM has its place in health care, but its limited and dangerous. Limited, because it demands the patient to be close to identical to whatever patient population has been sufficiently studied. Dangerous, because it encourages doctors to adopt algorithmic and rigid thought processes.

All I’m saying is that the alternative to the normalization of the genitals of infants isn’t something without risk (and I don’t think people understand that the opposite of “we cut, nobody makes fun of you” isn’t an endless stream of unicorns, teddy bears and rose petals.

If problems didn’t occur and this was simply a matter of “how bad does it have to be for us to cut and what is the best way?” it’d be a much simpler argument.
But it’s not.
We do need to know more, but we should probably tread carefully.

“Also I believe (although I have no personal experience with this) that m2f trans-gender prostitutes command a higher price than cis-male or cis-female prostitutes.”

Not really. Lots (far too many) of trans women are forced into survival sex work which doesn’t pay well. As a result of this, you’re also looking at a population with a 24% HIV+ rate as of the latest CDC studies. That’s trans women in general, not only trans sex workers.

Granted, there may be a niche, however it is not one which normally commands a high price. Maybe for a select clientele, but I suspect that is a small minority.

Anyone who thinks that there aren’t plenty of people out there who would be turned on by some slightly exotic equipment is spending way too much time at catsinsinks and not enough at xtube. Do you have any idea how popular ‘chicks with dicks’ are? Humans are remarkably adaptable, even voracious, in their peccadilloes.

@Antinous:
I agree that male circumcision is not particularly on-topic. But neither is female genital cutting, which for some reason the title of this article inappropriately references. These are intersex children. Female genital cutting is only relevant insofar as these doctors have *decided* that these babies should be female, which is specious at best.

I have a big problem with this entire issue being framed as being about little girls (almost everywhere I read about it), because it’s forcing an identity on the actual children involved–the same identity that these non-consensual surgeries forced on them. This is not female genital cutting, it is intersex genital cutting.

And don’t get me wrong, I’m not saying this to minimize one or maximize the other. Both are horrible. But the distinction is important to make until these children can decide for themselves what (if any) gender they identify as.

And for what it’s worth, I think talking about both male and female genital cutting can be quite relevant and valuable, because it helps us examine the issue at hand with respect to our attitudes toward other non-consensual genital modifications.

Advocates for Informed Choice is a non-profit organization advocating for the legal and human rights of children with intersex conditions or differences of sex development, like the ones in this story. We work in collaboration with bioethicists, doctors, parents, affected adults, and many others. If you are interested in taking action to help protect these children, and to be sure that possible human rights violations are investigated, please join our Facebook page at http://ow.ly/20wTY or sign up for our Twitter feed at http://twitter.com/aiclegal. You can also donate to support our work at http://aiclegal.org/we-need-your-supportâ€¦

I am not aware how many comments here are from intersex people or who are simply expressing an opinion based on some practical experience of the subject. All opinions are welcome of course, especially informed opinion, but my own direct experience is that intersex people are often the last point of reference regarding procedures that will, in some way affect their lives forever.

Surgery to remodel the genitalia of intersex people, especially infants in the name of conformity has its roots in the now challenged model of the human species being the one mammalian form on this planet that is totally bipolar in both phenotype and sexuality. Any variation is barely tolerated in our 21st century society which is still far closer to our primitive beginnings that the sophisticated modern creatures we like to imagine ourselves to be. Our ancestors had a very real reason to fear variation as often, survival relied on a fairly simple model of sex and gender. In contrast, it was within some of these early societies (e.g. Native American) that acceptance and celebration of difference marked them out as being in-advance of the issues and opinions we are still debating now. As Professor Milton Diamond (international authority on intersex and transsexual issues) said “Nature loves diversity, society hates it.”

The comparison with other conditions such as cleft lip (cheiloschisis) is rather risky. Surgery to repair this congenital condition is not a cosmetic procedure. Certainly, it does achieve a repair that allows the child to present with a typical, closed upper lip. However, the need for the surgery is primarily indicated by medical factors. A child with a cleft lip may suffer recurrent ear infections (the defects make children prone to build up of fluid in the middle ear) and pneumonia. Cleft lip is often associated with a cleft palate (palatoschisis) in which the roof of the mouth is open. This condition can lead to a child having difficulty with eating, drinking and speech problems later in life if the defect isn’t treated early.

Surgically altering the genitalia of an intersex infant is NOT usually medically necessary. but is in-fact, a cosmetic procedure dictated by social rules that change from culture to culture and era to era. There is NO research that demonstrates that children brought up with ambiguous genitalia suffer psychologically in later life. There is however, evidence that reveals that many of those who have undergone surgery do experience both negative medical and psychological consequences.

Apart from the fact that any surgery on an infant is a non consensual procedure, we as a society must make sure that the reasons for any surgery are truly medically necessary rather than based on ignorance and prejudice. I approach this from both sides of the fence – I was born with an intersex condition, was surgically ‘modified’ and have suffered both physically and psychologically all my life. I am also a professional who has worked with intersex children, Not only did the surgery alter my genitalia, but it also converted my genetically determined sex and subsequent gender role to one with which I could not identify. I had to fight to reclaim the right to live my life commensurate with my gender identity.

What the surgery does not do is change the brain and if a child’s brain is already hard wired to follow the gender identity opposite to the altered body they are forced to grow up with, the trauma is often too much for many to bear. Even those who undergo surgery which does not contradict the child’s gender identity (e.g. girls with Congenital Adrenal Hyperplasia (CAH) who identify as female. but present with an enlarged clitoris) can experience problems with lack of genital sensitivity – a feature that does wonders for their future sex lives. I have counselled many parents on this subject and am constantly amazed at the reasons given as to why they feel that their precious child should undergo general anaesthesia (a risk in itself) and their tiny genitals be cut and reconstructed to enable them to have a “better life”. Further questioning often reveals that the real reason is a mixture of “what would the baby sitter think if she had to change our child’s nappy?” …. “What will our family say?”… How could we face our friends / the neighbours?” … “We have already painted the nursery” (I am not joking) and from the medical profession “this is necessary for the child’s mental health” (no proof offered) “the parents want this” (since when have medical professionals done exactly what a relative (as opposed to the patient) wants?

The solution is simple – hold back from surgery other than in cases where there is a clear medical need such as a deformed urethra, but consider carefully what gender role to assign to the child (with CAH, most children with an XX karyotype ID as female). This can be determined before he/she starts school as by the age of two or three years most children will start to express their gender identity anyway.

When the child is old enough to make informed decisions for themselves, possibly aided by parents, counsellors and other intersex people who can offer advice based their experiences, surgery can be considered. My own training showed me that the human phallus (clitoris or penis) comes in many shapes and sizes, so who can say what is ‘normal’? Those who say that they could never contemplate going to school with a slightly enlarged clitoris are not able to speak from experience. A survey done with a group of women, none of whom had been diagnosed with clitoromegally were asked what they would choose to do about a larger than average clitoris if they were also warned that no surgery is without risk and post-operatively, they may find that the results are far worse than the condition that the surgery sought to address. There are risks of major complications which can include scarring, contractures, loss of sensation, loss of capacity for orgasm, and unsatisfactory appearance. Not surprisingly, all the women said that they would refuse the surgery. Many intersex infants are not afforded the same choices.